Running Head: THE LET IT GO GROUPcounsellingwithrobyn.weebly.com/uploads/7/0/0/6/70069161/the_let... · Running Head: THE LET IT GO GROUP ! The Let it Go Group for Anxiety: A Group

Running Head: THE LET IT GO GROUP

The Let it Go Group for Anxiety: A Group Therapy Proposal

An 8-week psychoeducational group therapy program for youth aged 12 to 17 years

Molly Hayes and Robyn Polsfut

University of Lethbridge

CAAP 6637

Dr. Elaine Greidanus

THE LET IT GO GROUP 2

Abstract

Young people experience intense biopsychosocial transitions during adolescence that trigger

developmentally appropriate anxiety responses. However, many youth experience disordered

anxiety that impacts their ability to lead fulfilled intrapersonal and interpersonal experiences and

leave them at-risk for developing adulthood depression and anxiety. The Let it Go Group for

Anxiety is a proposed 8-week psychoeducational group therapy program for youth aged 12 to 17

years that utilizes the philosophies and techniques of cognitive-behaviour therapy (CBT) and

acceptance and commitment therapy (ACT). The Let it Go Group aims to convey an accurate and

developmentally appropriate understanding of anxiety for young people and facilitate the

learning of effective individual and group strategies for dealing with anxiety in a safe social

environment in order to reduce the overall negative experiences of anxiety in youth. The main

topics of the program include education about anxiety, the theoretical basics of CBT and ACT,

anxiety management tools including mindfulness and emotional regulation skills, social skills,

and communication skills.


Table of Contents

Background --------------------------------------------------------------------------------------------- 4 Overview of Anxiety in Youth ------------------------------------------------------------------------ 4 General Treatment Needs------------------------------------------------------------------------------- 5 Rationale for Proposed Program for Youth with Anxiety------------------------------------------ 6 Proposed Group Program ---------------------------------------------------------------------------- 8 Overview of The Let it Go Group for Anxiety-------------------------------------------------------- 8 Group Goals ---------------------------------------------------------------------------------------------- 9 Ethical Considerations -------------------------------------------------------------------------------- 11 Principle I: Respect for Dignity of Persons ---------------------------------------------------------- 11 Principle II: Responsible Caring ---------------------------------------------------------------------- 14 Principle III: Integrity in Relationships -------------------------------------------------------------- 16 Principle IV: Responsibility to Society --------------------------------------------------------------- 17 Marketing ----------------------------------------------------------------------------------------------- 18 Group Membership and Screening ----------------------------------------------------------------- 18 Inclusion Criteria ---------------------------------------------------------------------------------------- 19 Exclusion Criteria --------------------------------------------------------------------------------------- 20 Group Details ------------------------------------------------------------------------------------------- 20 Pre-Group Meeting -------------------------------------------------------------------------------------- 20 Post-Group Meeting ------------------------------------------------------------------------------------- 23 Group Format and Session Structure ----------------------------------------------------------------- 24 Weekly Topics ------------------------------------------------------------------------------------------- 24 Note Taking and Record Keeping --------------------------------------------------------------------- 28 Group Evaluation and Feedback ---------------------------------------------------------------------- 29 References------------------------------------------------------------------------------------------------ 31 Appendices ---------------------------------------------------------------------------------------------- 38 Appendix A: Parent Marketing Poster ---------------------------------------------------------------- 38 Appendix B: Youth Marketing Poster ---------------------------------------------------------------- 39 Appendix C: Informed Consent Package ------------------------------------------------------------ 40 Appendix D: Individual Session Note Template ---------------------------------------------------- 48 Appendix E: Group Session Note Template --------------------------------------------------------- 49 Appendix F: Exit Slip ----------------------------------------------------------------------------------- 50 Appendix G: Final Group Evaluation ---------------------------------------------------------------- 51


Background

Overview of Anxiety in Youth

Anxiety is described as an anticipation of potential future threats and can be characterized

by uncomfortable symptoms of emotional and physical arousal (American Psychiatric

Association (APA), 2013). In response to stressful situations, anxiety responses can be normal,

however, excessive, persistent, and situation-inappropriate anxiety reactions are characteristic of

disordered anxiety (APA, 2013). Adolescence is a period where youth tend to display an

increased concern for peer evaluation and acceptance, awareness of self, sense of social inclusion

and exclusion, and awareness (Kendall & Ollendick, 2005). Developmental experiences of youth

are highly transitional (Kendall & Ollendick, 2005) and encourage anxiety reactions (Seligman

& Ollendick, 2011). Consequently, it is developmentally appropriate to have fears and process

anxiety-provoking experiences (Beesdo, Knappe, & Pine, 2009; Seligman & Ollendick, 2011).

However, Beesdo et al. (2009) noted that approximately 15-20% of youth experience some form

of disordered or maladaptive anxiety during adolescence that interferes with the ability to engage

in developmentally appropriate situations.

Anxiety disorders are among the most common conditions affecting youth (Costello, Egger,

& Angold, 2005; O’Neil, Podell, Benjamin, & Kendal, 2010) and tend to be comorbid with other

disorders (Kendall et al., 2010). Experiences of anxiety in youth tend to be comorbid with

depressive symptoms (Sood & Kendall, 2007; Suveg et al., 2009; O’Neil et al., 2010; Kendall et

al., 2010). Sood & Kendall (2007) explained that youth with anxiety tend to experience more

negative self-talk than non-anxious youth. Negative self-talk tends to trigger depressive

emotional, behavioural, and additional negative cognitive reactions (Sood & Kendall, 2007).


O’Neil et al. (2010) found that anywhere from 12 to 50% of anxious youth experience significant

depressive symptoms during adolescence.

The experience of anxiety has significant psychosocial impacts on youth (Suveg et al., 2009).

Youth with anxiety tend to be more socially withdrawn (Mychailyszyn, Méndez, & Kendall,

2010), display an overall deficit in social functioning and tend to struggle academically (Suveg et

al., 2009; Mychailyszyn et al., 2010). Deficits in the social and educational domains contribute to

lower self-esteem, an increase in negative self-talk and other depressive symptoms (Kendall &

Ollendick, 2005; Suveg et al., 2009; Mychailyszyn et al., 2010). Although there is a

developmental tendency of youth to experience anxiety, anxious youth are also at high-risk of

developing long-term depression and anxiety in adulthood (Kendall & Ollendick, 2005;

Mychailyszyn et al., 2010).

General Treatment Needs

Based on the unique developmental and social characteristics of adolescents, treatment

programs for anxiety in youth have some specific needs. Adolescence is a developmentally

diverse period and therefore catering to the interests and abilities of the clientele is essential to

therapeutic success (Kendall et al., 2006; Thompson & Gauntlett-Gilbert, 2008). Similarly, due

to the distinct interest in social evaluation of youth (Kendall & Ollendick, 2005), treatment plans

must feature goals that align with social acceptance and have peer-related applicability (Kendall

& Ollendick, 2005; Kendall et al., 2006; Kendall & Treadwell, 2007). Treatment plans should

also feature the facilitation and development of skill-based coping mechanisms (Kendall &

Ollendick, 2005; Kendall et al., 2006; Kendall & Treadwell, 2007; Thompson & Gauntlet-

Gilbert, 2008; Garber & Weersing, 2010; Seligman & Ollendick, 2011). Kendall and Ollendick

(2005) and Seligman and Ollendick (2011) suggested that treating anxiety in youth focus on


social skills, communication, cognitive and emotional regulation skills in a strength-based format

that features goal-setting. Kendall et al. (2006) and Thompson and Gauntlet-Gilbert (2008) added

that treatment for youth should feature teaching youth skills to realistically assess anxiety-

provoking situations and offer coping mechanism alternatives such as relaxation and

mindfulness. Kendall and Treadwell (2007) and Garber and Weersing (2010) urged that

treatment also focus on depressive symptoms, specifically negative self-talk. Developing and

maintaining rapport is essential for an effective therapeutic alliance, however Kendall and

Ollendick (2005), Kendall et al. (2006), and Seligman and Ollendick (2011) noted that when

working with youth, it is also important that therapists align and develop rapport with both

parents and their youth clients. Regular consultation with youth in particular throughout the

therapeutic process is particularly important for therapeutic success (Kendall et al., 2006).

Rationale for Proposed Program for Youth with Anxiety

The development of dysfunctional coping mechanisms in adolescence promotes the

maintenance of such maladjustment into adulthood and leaves youth at risk of developing long-

term anxiety and depression (Kendall & Ollendick, 2005; Mychailyszyn et al., 2010; Rosselló,

Bernal, & Rivera-Medina, 2012). Group therapy is an appropriate intervention medium for

treating anxiety in youth (Flannery-Schroeder, Choudhury, & Kendall, 2005; Hyun, Chung, &

Lee, 2005; Asbahr et al., 2005; Thompson & Gauntlet-Gilbert, 2008; Mychailyszyn et al., 2010;

Rosselló et al., 2012). In their study of group cognitive behaviour therapy (CBT), Flannery-

Schroeder et al. (2005) found that 77% of their youth subjects no longer met the diagnostic

criteria for anxiety disorders 12 months post-treatment. Similarly, Thompson and Gauntlet-

Gilbert (2008) found that offering anxiety interventions in a group therapy setting increased the

efficacy of the treatment approach by offering a venue for peer support. Asbahr et al. (2005)


concluded that peer interactions and support in the therapeutic setting contributed to a decrease

in symptom relapse of obsessive-compulsive disordered youth. Asbahr et al. (2005) found that

group therapy offered youth with unique opportunities to learn through modeling, exchanging

experiences, and receiving personalized information about coping mechanisms, and

interventions. Mychailyszyn et al. (2010) and Rosselló et al. (2012) explained that without a

group setting, youth with anxiety are unable to practice social skill development in a socially safe

environment. The work of the above-mentioned researchers provides sufficient rationale for the

use of group therapy to treat youth with anxiety.

Acceptance and commitment therapy (ACT) and CBT offer effective treatment options

for youth with anxiety (Arch & Craske, 2008). Both therapeutic approaches encourage an

objective perspective on emotions, cognitions, and actions (Arch & Craske, 2008), address

avoidance behaviours, utilize self-talk techniques (Burke, 2010; Seligman & Ollendick, 2011),

and are considered appropriate for facilitation in group settings (Hyun et al., 2005; Flannery-

Schroeder et al., 2005; Arch & Craske, 2008; Suveg et al., 2009). The designated subheadings

below provide additional rationale for the use of both ACT and CBT approaches to treat youth

with anxiety.

ACT. ACT is a behavioural approach that uses mindfulness, non-judgmental acceptance, and

cognitive defusion to increase psychological flexibility and promote behaviour change towards

personal choice (Arch & Craske, 2008; Burke, 2010). In group settings, Arch and Craske (2008)

found that ACT offers effective psychoeducation to youth about anxiety and depression, and

promotes peer support for relaxation techniques. Thompson and Gauntlet-Gilbert (2008) found

that ACT practices promoted emotional stability and self-awareness in young people suffering

from anxiety symptoms. Self-awareness, flexibility, and emotional stability are characteristics


considered necessary for maneuvering the transitional stages of adolescence (Thompson &

Gauntlet-Gilbert, 2008). In addition to the developmental applicability of ACT practices with

youth, Gilbert and Procter (2006), Burke (2010), and Vøllestad, Nielsen, and Nielsen (2012)

found that ACT techniques effectively decreased anxious and depressive symptoms associated

with anxiety in youth.

CBT. CBT is based on the principle that thoughts, feelings, and actions have reciprocal

relationships with each other that allows one to influence the other and vice versa (Wright,

Basco, & Thase, 2006). Similar to the ACT approach, CBT utilizes self-talk to restructure

cognitions to promote adaptive behaviours (Kendall et al., 2006). Several researchers found CBT

to be successful at decreasing anxiety symptoms including Walkup et al. (2008), Flannery-

Schroeder et al. (2005), Garber and Weersing (2010), Seligman and Ollendick (2011), Kendall et

al. (2006), and Sood and Kendall (2007). Specifically, Walkup et al. (2008) noted a decrease in

insomnia, fatigue and restlessness following CBT treatment of youth with anxiety. Sood and

Kendall (2007) and Seligman and Ollendick (2011) explained that the skills approach of CBT

contributed to the long-term success of anxiety treatment in youth. Rosselló et al. (2012) and

Suveg et al. (2009) found that CBT improved the adaptability of youth people suffering from

anxiety and associated depressive symptoms. Specifically, CBT contributed to an increase in

social activities with peers, school performance (Suveg et al., 2009), and emotional stability in

unpredictable social situations (Rosselló et al., 2012).

Proposed Group Program

Overview of The Let it Go Group for Anxiety

The program that we are proposing, titled The Let it Go Group for Anxiety (also referred

to as The Let it Go Group) is a group-style, psychoeducational group for youth struggling with


anxiety and anxiety-related concerns. The Let it Go Group program is largely psychoeducational

in nature focused on teaching youth skills for dealing with their individual needs with regards to

anxiety. The Let it Go Group is theoretically oriented in CBT and ACT. These orientations were

chosen due to the vast amounts of research validating their efficacy in reducing the experience of

anxiety in a youth population (Gearing, Schwable, Lee, & Hoagwood, 2013; Bennett et al., 2013;

Hudson et al., 2015; Arch et al., 2012). The Let it Go Group’s key themes include learning about

anxiety, learning the theoretical basics about cognitive behavioural and acceptance and

commitment therapy, managing anxiety in the here-and-now, developing emotional regulation

skills, social skills training, learning how to effectively communicate, and provide support to

others and for ourselves (Seligman & Ollendick, 2011; Purini, Wurthrich, & Rapee, 2013).

Because The Let it Go Group is rooted within teaching as a group versus processing as a group

(as traditionally seen in a therapeutic group setting) our themes are meant to be gauged by each

individual in the group and practiced at their own volition outside of group, however practicing

skills is encouraged within group meetings (Vassilopoulos, Brouzos, Damer, Mellou,

Mitropoulou, 2013). The Let it Go Group program consists of eight sessions, one session per

week, running for an hour and a half. Our ideal group would range between 10 and 15

participants with all participants aged between 12 and 17. A detailed outline of each of these

eight sessions will be provided further in this document.

Group Goals

To reiterate, The Let it Go Group program’s predominant goal is to create a group-

learning environment where youth can practice and engage new skills for dealing with their

individual experience of anxiety. More specific group goals are meant to provide impetus and

direction to group facilitators and also be shared with group participants. Specific group goals of


The Let it Go Group are to cultivate an understanding of what anxiety is, learn new individual

and social strategies for dealing with anxiety, and reduce the negative experience of anxiety.

These goals were chosen due to their fit within our psychoeducational approach to group

learning in treating anxiety as well as for their fit within current anxiety prevention in youth

literature.

Barrett, Farrell, Ollendick, and Dadds (2006) evaluated a CBT-based education program

aimed at preventing anxiety. Their data indicates that in the youth population with a diagnosed

anxiety disorder symptoms were reduced post-group and the effect maintained up to three years

post-group (Barrett et al., 2006). Their research also indicates that those youth without an anxiety

disorder who participated in the program continued to have low levels of self-reported anxiety

three years post-group (Barrett et al., 2006). This research is significant because it demonstrates

the efficacy that education can have on the reduction of anxiety and the maintenance of anxiety-

reducing behaviours (Barrett et al., 2006).

Literature of similar findings are vast suggesting that an education approach to the

treatment of anxiety is beneficial across the youth population, produces long-lasting effects, and

is cost effective (Greenberg et al., 2003; Barrett, Lock, & Farrell, 2005; Farrell & Barrett, 2007).

Cognitive behavioural therapies are most-often cited as the theoretical orientation for these

programs as CBT is a therapist-directive style of treatment and is highly structured, rooted in

learning, and effective influencing our program’s theoretical orientation (Wright et al., 2006;

Barrett et al., 2006; Farrell & Barrett, 2007; Gearing et al., 2013; Hudson, et al., 2015). This

pairing of education with CBT and ACT techniques for dealing with anxiety is a potent and

natural fit, which will be demonstrated throughout The Let it Go Group session information

provided further in this document.


Ethical Considerations

There are several important ethical considerations to make when working with anxious

youth in therapeutic group settings. In this section, the Canadian Psychological Association

(CPA) Canadian Code of Ethics for Psychologists (2000) principles will be used a framework

for the discussion pertaining to counselling work with anxious youth in therapeutic group

settings. The designated subheadings below state the principles of the Canadian Code of Ethics

for Psychologists (CPA, 2000) and offer applicable ethical considerations for general counselling

work with clients in group settings and more specifically counselling work with youth, and with

anxiety-related topics. Where applicable, the Canadian Counselling and Psychotherapy (CCPA)

(2007) Code of Ethics standards will be referred to provide additional ethical considerations.

Principle I: Respect for Dignity of Persons

Principle I: Respect for Dignity of Persons refers to the promotion and protection of

rights to privacy, self-determination, personal liberty, and natural justice for all people regardless

of any personal characteristic, condition, or status including but not limited to culture, age,

gender, sex, sexual orientation, race, ethnicity, and physical or mental abilities (CPA, 2000).

Respect for the dignity of others also recognizes that with decreased personal power due to

vulnerabilities, psychologists have an increased responsibility to protect and promote rights

(CPA, 2000). Principle I offer several subcategories of ethical standards; recommendations that

are particularly applicable to work with groups, youth, and anxiety are discussed below.

Principle I: working with groups. Group therapy by definition involves the bringing

together of individuals who have various characteristics, conditions, and/or statuses for work

towards a common goal (Corey, Corey, & Callanan, 2011). In order to respect the dignity of all

group members, group leaders have a responsibility to ensure that activities do not isolate,


exclude, or discriminate against any group member, including those that are vulnerable or might

be disadvantaged in anyway (CPA, 2000). Group activities therefore must reflect cultural

competence, non-discriminatory practices, and be developmentally appropriate (Corey et al.,

2011). Similarly, to appropriately respect the right to terminate or withdraw from the therapeutic

activities, group members are not required to participate in activities despite and may “pass” at

any time. In order to ensure that all members are treated fairly and are exposed to due process,

fees for therapy must be fair. When working with groups, it therefore may be more appropriate to

offer a fee scale to accommodate various financial situations.

Informed consent involves offering clients with all the necessary information pertaining

to their therapeutic experiences in order for them to maintain their right to make autonomous

decisions about such experiences (Corey et al., 2011). The CPA (2000) explained that informed

consent involves the full and active participation of clients and others who are impacted by

therapeutic decisions. Additionally, informed consent must cover at least the purpose, nature,

benefits and risks of the intended therapeutic activities, mutual respect of rights, confidentiality

protections and limitations, therapeutic alternatives, and the rights to refuse or withdraw consent

(CPA, 2000).

Group therapy can involve the disclosure of personal information such as memories,

feelings, and thoughts with others who are not legally held to the CPA ethical standards and

therefore informed consent for group members must include additional confidentiality and

privacy limitations amongst group members. In order to protect the privacy and confidentiality of

group members, group facilitators may keep records on group members but will not include the

names of other members (Corey et al., 2011). Group members will be asked to remain respectful

of others’ rights to privacy and confidentiality by following group expectations (CPA, 2000). In


order to account for the potential social pressures to consent, a violation of freedom of consent

(CPA, 2000), group work should involve a two-step informed consent procedure where

individual group members discuss and sign documents privately (step one), and review the

documents as a group (step two).

Principle I: working with youth. In Alberta, people under the age of eighteen are not able

to consent for themselves (College of Alberta Psychologists (CAP), 2007) they meet the CPA

(2000) requirements for vulnerable persons. Therefore, working with minors presents some

limitations to the rights to informed consent, privacy, and confidentiality that require an

increased responsibility to promote such rights. With the exception of youth who receive mature

minor status and emergency situations, parents or guardians must give consent for youth to

engage in therapeutic practices (CAP, 2007). However, the ethical standards of the CCPA (2007)

and CPA (2000) promote autonomous choices of all clients despite their legal ability to consent.

Therefore, working with youth involves respecting their rights to refuse participation despite

their guardians’ signatures on an informed consent document.

To protect the vulnerability of young people, obtaining consent from minors also requires the

use of developmentally appropriate methods for explaining the elements of informed consent

(CPA, 2000). Parents or guardians of minors have the right to request documentation from their

dependent minor’s therapeutic sessions (CAP, 2007). Therefore in order to respect the dignity of

non-consenting youth, informed consent documents must outline this additional limitation to

privacy and confidentiality.

Principle I: working with anxiety. One ethical issue pertaining to respecting the dignity

of persons that relates specifically to therapeutic work with anxiety involves the non-

discriminatory and fair treatment of clients in an anxiety-specific therapeutic group setting.


Recognizing the individuality of anxiety-related experiences is important to develop rapport with

clients (Norton & Hope, 2005), therefore facilitating a general anxiety therapy group risks

isolation or exclusion of particular experiences. However, Norton and Hope (2005) also noted

that the similarities in anxiety diagnoses and experiences how weigh the differences and

therefore group therapy offers effective treatment for people suffering from anxiety disorders.

Principle II: Responsible Caring

Principle II: responsible caring refers to the extra attention psychologists give to ensure

that benefits of therapeutic activities outweigh the potential harm (CPA, 2000). Responsible

caring involves predicting benefits and risks, acting to minimize harm and maximize benefits,

and working to correct or offset potential harm (CPA, 2000). Principle II offers several

subcategories of ethical standards; recommendations that are particularly applicable to work with

groups, youth, and anxiety are discussed below.

Principle II: working with groups. Responsible caring in various therapeutic settings

involves acting within the range of one’s competence and referring to other services if a client

requires care that one is unable to provide (CPA, 2000). When working with groups, meeting the

needs of various clients at one time poses an ethical challenge. In order to offset the risk for

potential harm that exists when group leader facilitate work towards common goals, rather than

individual goals, group work will be limited to specific group goals and resources will be

provided for related services. Group activities will also reflect the highest of cultural competence

in order to minimize the risk for harm and maximize the benefits (CPA, 2000). To offset harm,

group activities are no longer benefiting a group member, or that group member is posing a

potential risk for harm to other group members, that member will be referred to other therapeutic

services in order to minimize harm and maximize benefit for all group members (CPA, 2000).


Additionally, all group members will be screened for suitability for group work and for work

within the specific goals of the group.

Group work often entails the sharing of facilitation between two qualified counsellors (Corey

et al., 2011). Co-facilitation presents some ideal scenarios for responsible caring such as the

opportunity for group members to receive additional feedback from more than one professional

(Corey et al., 2011). Provided that co-facilitators display functional interpersonal interactions,

they can offer effective modeling for members and offer each other appropriate peer support and

responsibility-sharing (Corey et al., 2011). However, in the event that co-facilitators are a

dysfunctional team, Corey et al. (2011) noted that co-facilitation can incidentally model

ineffective communication, inappropriate competition, and dependence. To maintain responsible

care of group members, it is imperative that co-facilitators practice self-awareness and resolve

interpersonal issues; supervision as a pair is appropriate and recommended (Corey et al., 2011).

Principle II: working with youth. As mentioned in the discussion about respect for dignity

of persons, youth are a vulnerable population (CPA, 2000). Although guardian or parental

informed consent is obtained for therapeutic activities, the potential risks and benefits of such

activities must be explained to youth. Working with vulnerable populations requires that

therapists act to minimize the impact of their innate power of influence on the decision making

of the client (CPA, 2000). Ensuring that youth are provided with necessary and sufficient

information and support for autonomous actions encourages responsible caring (CCPA, 2007).

Principle II: working with anxiety. Responsible caring when treating various forms of

disordered thinking involves evidence-based practices to ensure that the best opportunities for

benefits are provided at the smallest potential risk (CPA, 2000). Davis, May, and Whiting (2011)

concluded that children with anxiety do not respond equally to treatment; some techniques work


better than others for some children despite their diagnoses. Children who do not receive benefits

from therapeutic techniques used can become treatment-resistant (Davis et al., 2011) and

therefore increased exposure to non-beneficial techniques may be increased the risk for potential

harm.

Principle III: Integrity in Relationships

Principle III: integrity in relationships refers to the promotion of accuracy and honesty,

openness, the maximization of objectivity, minimization of bias, and the avoidance of conflicts

of interest (CPA, 2000, p. 22). Integrity in therapeutic relationships involves recognizing how

one’s background, personal needs, and values interact with their therapeutic activities (CPA,

2000). When an interaction between a therapist’s personal preferences and their therapeutic

activities exists, therapists are required to be open and honest about it, and work to act

objectively in response to it (CPA, 2000). Principle III offers several subcategories of ethical

standards; recommendations that are particularly applicable to work with groups, youth, and

anxiety are discussed below.

Principle III: working with groups. Like with individual therapy, it is important to disclose

and discuss the limitations of a therapist’s skills and chosen interventions with group members

before engaging in the activity (CPA, 2000). Instructions for the activity are to be provided

accurately, clearly, and without bias (CPA, 2000). Conflicts of interest are more likely to occur

in group therapy sessions because of the exposure of clients to other clients (i.e. group members)

(Corey et al., 2011). In an attempt to offset potential conflicts of interests amongst group

members, group rules will dictate the expectation to respect the privacy and confidentiality

outside of therapeutic settings and will be encouraged to inform group leaders if a potential

conflict arises (Corey et al., 2011). Additionally, group facilitators will not offer rewards for


engaging in activities in order to promote a lack of bias and avoid conflicts of interest (CPA,

2000).

Principle III: working with youth. Promoting the integrity of relationships when working

with youth in therapeutic settings involves providing developmentally appropriate instructions,

and information about the limitations of skills and interventions (CPA, 2000). Therapists have a

“responsibility to maintain competence in any specialty area for which they declare competence”

(CPA, 2000, p. 23). Working with youth may require special training (Corey et al., 2011) and

therefore maintaining such competence is essential for respecting the integrity of therapeutic

relationships with youth.

Principle III: working with anxiety. Clients who suffer from anxiety may be reluctant to

engage in therapeutic activities due to fears or worries (Davis et al., 2011). Providing additional

accurate information about the benefits and limitations of particular interventions may decrease

concerns and improve participation in therapy. Encouraging an open exchange of information

and concerns pertaining to therapeutic practices not only builds rapport (Corey et al., 2011) but

also reflects integrity in therapeutic relationships (CPA, 2000).

Principle IV: Responsibility to Society

Principle IV: responsibility to society refers to a therapist’s responsibility to promote the

welfare of all people within the societal groups they are exposed to (CPA, 2000). Responsibility

to society involves therapists working with other professionals, practicing self-reflection, and

being open to evaluations and suggestions offered to them regarding psychological practice

(CPA, 2000). With regards to group work, group leaders have a responsibility to encourage

feedback from group members in order to ensure that societal groups are respected within the

therapeutic group. Receiving non-biased feedback from youth involves offsetting existing power


differentials, and offering mediums of evaluation that are developmentally appropriate. Based on

the work of Davis et al. (2011) it is also important to ensure that collaborative services are

available to clients who suffer from anxiety and may not be benefitting from the therapeutic

practices offered by the therapist.

Marketing

In order to cater to the interests and consent limitations of the desired clientele of The Let

it Go Group, marketing strategies will be two-fold. One component of the strategy will be

designed specifically for parents. A hardcopy poster (see Appendix A) that outlines the group

goals and registration information will be put up on community bulletin boards in coffee shops,

recreation facilities, and staffrooms. The other component of the strategy will be targeted

specifically at youth aged 12 to 17 years. Social media campaigns on Twitter, Facebook, and

Instagram will offer stress tips and group information using digital posters (see Appendix B) and

the hashtag #notaboutfrozenanymore.

Group Membership and Screening

While research indicates that psychoeducational groups can be beneficial and reduce

anxiety across the youth population (Barrett et al., 2005; Barrett et al., 2006), The Let it Go

Group strives to work with youth already experiencing the negative effects of anxiety in their

everyday lives. It is for this reason that our group will not be open to all who might have an

interest in learning about anxiety, but reserved for those specifically experiencing anxiety. It is

important to note that a diagnosis of an anxiety disorder is not necessary for inclusion within The

Let it Go Group. We recognize the need for pre-group screening that is both standardized and

semi-structured (interview style) to ensure appropriate participant selection.


We will use three standardized screening tools; two address anxiety and its

symptomology, and one assessing depression and depressive symptomology. To assess for

anxiety we will use the Spence Children’s Anxiety Scale (SCAS) and the Revised Children’s

Manifest Anxiety Scale (RCMAS). Both of these measures are self-report measures and have

high reliability and validity (Spence, Barrett, & Turner, 2003; Seligman, Ollendick, Langley, &

Baldacci, 2004). The SCAS score will help categorize the type of anxiety the youth is

experiencing while the RCMAS will be used to gauge the severity of the symptoms (Spence,

Barrett, & Turner, 2003; Seligman et al., 2004). The RCMAS will be used as a pre-group and

post-group measure of progress for the participants. This screening tool lends itself well to this

purpose as it is related to the severity of the experience of anxiety symptoms. Our rationale for

assessing depression as well as anxiety is to ensure that our participants are in fact experiencing

anxiety and not another mood disorder, most commonly related to the experience of anxiety is

depression (Cohen, Young, Gibb, Hankin, & Abela, 2014). Using the Children’s Depression

Inventory (CDI) we will be able to see if depression is a concern for this youth and also if their

depressive symptoms are more or less pervasive than their anxiety symptoms.

During the screening process we will also engage the youth in a semi-structured

interview encompassing more life factors than the screeners mentioned above. The nature of this

interview, and the questions asked throughout, will vary from participant to participant, however

the following topics will be discussed: family history; early childhood medical history; any

experience with trauma; and suicidal ideation.

Inclusion Criteria

Youth will be accepted into our program who are between the ages of 12 and 17 whose

primary mental health concern is anxiety-related. Individuals with SCAS and RCMAS scores


that are higher than their CDI score will be included. As we hope to encompass a wide range of

adolescents experiencing anxiety there is no minimum score on the SCAS and RCMAS to ensure

admission, simply that their predominant concern is anxiety and that it is identified by the

screeners in some way.

Exclusion Criteria

Youth will be excluded from our program who are younger than age 12 whose primary

mental health concern is not anxiety-related. Individuals with CDI scores surpassing their SCAS

and RCMAS scores will not be included in this program, but referred to a more appropriate

depression-related group or treatment. Youth who are experiencing post-traumatic stress or

appear to be experiencing post-traumatic stress disorder (PTSD) will not be included in this

group, and will be referred to a PTSD-specific treatment. Further, youth who are actively

suicidal will not be included in our group as this matter is best addressed promptly and

specifically (O’Neil, Puleo, Benjamin, Podell, & Kendall, 2012).

Group Details

Pre-Group Meeting

Hannah (2000) explained that pre-group meetings improve the efficacy of the therapeutic

program, and help to foster engagement in essential group therapy processes by familiarizing

group members with the processes and conditions of the group. The purpose of The Let it Go

Group pre-group meetings are to convey the conditions and expectations of the group, facilitate

informed consent, and conduct pre-group assessments to determine inclusion of potential group

members. For legal consenting purposes, pre-group meeting invitations will be offered to

potential youth group members and at least one of their legal parents or guardians. Pre-group

meetings will be approximately one hour in length and will include a tour of The Let it Go


Counselling Centre. The follow subsections outline the proposed pre-group meeting plan for The

Let it Go Group.

Initial phone interview. Upon receiving application interests (via phone or social

media), parents will be contacted to discuss pre-group meetings. During this initial phone

interview, parents will be asked about the age of their adolescent (as stated in previous sections,

only youth aged 12 to 17 will be accepted for the pre-group meeting component). The cost of

The Let it Go Group is $500.00 per participant, however, following ethical standards (CPA,

2000), financial status will not be a barrier to treatment and thus a lower fee will be offered to

parents if necessary. If a participant drops out, refunds will only be provided based on

appropriate and unforeseen circumstances. Group members will not be replaced once The Let it

Go Group program commences.

A review of the group goals. The Let it Go Group pre-group meetings will involve a

discussion of Hannah’s (2000) suggested conditional topics. Hannah (2000) explained that in

order for group members to feel empowered and supported, group facilitators must review the

intention of the program. A review of the group goals will be geared towards the youth group

member and will offer check-ins with the parent/guardian to ensure that both parties understand

the group structure, format, and intended activities. After allowing for questions and a discussion

of potential concerns, the facilitator will shift into a discussion about general expectations.

Discussion of general expectations. Hannah (2000) explained that group members must

be informed of topics such as commitment to the group, belief in democratic group processes,

value in honest here-and-now reflections during group, mutual support and acceptance amongst

group members, clarification of group facilitator roles, and a value in taking risks to encourage

the achievement of individual and group goals. It will be explained to youth that their


involvement in the group processes (i.e. attendance and activities) is essential for their personal

success and will assist others in their changes and therefore in order to be suitable for the

program, group members must commit to attendance to all sessions, and dedicate themselves to

involvement in the activities. Further, the expectation that group members warmly accept each

other and work to ensure that group processes reflect fairness and honesty will be explained. This

discussion will improve the efficacy of interventions used in the program, and allow group

facilitators to begin the process of developing rapport with group members (Hannah, 2000).

A review of the informed consent package. The next component of the pre-group

meeting will use The Let it Go Group informed consent package (Appendix C) as a guide. Based

on the ethical considerations reviewed in a previous section, the informed consent process is

intended to be collaborative and comprehensive (Corey et al., 2011). Following the order of the

consent package, potential youth group members and their parents will review the items with the

facilitator, allowing sufficient time for silent reading, verbal reading, and discussions. The Let it

Go consent package has three main parts: general consent information (“before we get started”),

minor information (“stuff you need to know because you're an adolescent”) and a review of all

topics (“final notes”). The Let it Go Group consent package meets all ethical requirements set by

the CPA (2000) and CCPA (2007) and features youth and consenting adult permission options.

Within the consent package, youth and their guardians/parents will review the role of the group

facilitators. Co-facilitators have been chosen based on their qualifications, skills, and their ability

to model appropriate interpersonal interactions together. At this time, both facilitators are of the

same gender. Although Yalom and Leszcz (2005) suggest co-facilitators be of opposite genders

to facilitate family-like interactions, the nature of The Let it Go Group does not require that

parenting styles be modeled and therefore, same-gender facilitators are ethically appropriate.


Screening for inclusion criteria. As explained in the inclusion and exclusion criteria

sections above, potential group members will engage in a semi-structured interview with group

facilitators. This discussion instills faith in the potential group member by allowing the facilitator

to convey their values, beliefs, and attitudes towards the group goals, targeted issues, and overall

dedication to counselling (Hannah, 2000). Following this discussion, group members will

complete three standardized assessment tools, as explained in the above sections, to determine

suitability for the program. Potential group members will then receive a tour of the facility and

will be informed of the follow-up procedure. All potential group members will be contacted

within two weeks of the pre-group meeting to be informed of their inclusion or exclusion to the

program.

Post-Group Meeting

Though The Let it Go Group is psychoeducational in nature, it can be predicted that

relationships will be formed. It is these relationships and group dynamics that can lead to

powerful client change (Karver, Handelsman, Fields, & Bickman, 2006). For this reason we will

conduct two post-group contacts with participants of the group. The first contact will happen two

weeks post group, via phone, to evaluate the youth’s overall experience at The Let it Go Group.

The second contact will be an optional group meeting for participants to catch up, share progress,

and further learnings since the group. This meeting will happen two months (eight weeks)

following the final group session and will take place in the same room and the same time as the

group had. This session will be relatively unstructured, a time for the participants to discuss their

successes and struggles since the group and perhaps be reminded of some helpful skills or learn

new tips from others in the group, which can contribute to long-term success and accountability

to change (Corey et al., 2011).


Group Format and Session Structure

The Let it Go Group will consist of 8 weekly sessions at the Let it Go Counselling

Centre, each an hour and half in length. Each session will offer different topics but will follow a

similar structure. The session structure is as follows: each group will start with a check-in where

participants respond to a prompt or complete a sentence, lead into education about the weekly

topic, describe activities as to how to take this knowledge home, and close with a check-out. Co-

facilitators will meet 30 minutes prior and following group sessions to plan and debrief together.

Additionally, following ethical suggestions for competence (CPA, 2000), co-facilitators will

receive supervision as a pair by a registered psychologist following sessions 2, 6, and 8

particularly pertaining to interventions and group dynamic maintenance.

Weekly Topics

The following is an overview of the objectives of each session of The Let It Go Group for

Anxiety. As described above, each session will be an hour and a half in length, and follow a

similar structure in that each group will start with a check-in where participants respond to a

prompt or complete a sentence, lead into education about the weekly topic, describe activities as

to how to take this knowledge home, and close with a check-out.

1. Introductory session

o Objectives: To review and explore informed consent; for learners to become

acquainted with each other; establish group rules and guidelines.

During the pre-group meeting each participant, along with their parents, went through the

process of informed consent, following CPA (2000) standards. However, as there has been a

small period of time (up to two weeks for some participants) and with each first session of a

group there is excitement, energy, and emotion for these reasons informed consent will be


reviewed again in detail. There will be time for the participants to ask any questions that they

might have, but we will take the initiative and discuss important reminders such as

confidentiality, autonomy, expectations of the group participants, and an overview of what to

expect from the group. The initial session can be awkward as participants become acquainted so

we will engage the group in a couple of ice-breaker activities to loosen things up. We do want

the participants to feel safe and included in this introductory session therefore we will ask them

to come up with their own group guidelines and rules. We will pop in and ensure that aspects of

informed consent are a part of these guidelines, however we will leave things like snacks and cell

phone breaks to the participants to decide on.

2. What is Anxiety? Cognitive Behavioural Therapy? Acceptance and Commitment

Therapy?

o Objectives: To engage the participants in the structure of group that can be

expected for the remaining seven sessions; teach the participants what anxiety is

and how it has been treated in the past, in other cultures, and in today’s society;

explore CBT and ACT and explain why we have chosen these theoretical

orientations and techniques for the Let It Go Group for Anxiety.

i. Part 1: Check-in, “I am hoping to learn _______ at the Let It Go Group for Anxiety.”

ii. Part 2: Anxiety, CBT, ACT lesson and discussion.

iii. Part 3: Check-out, “Today I learned _______.”

3. Self-Talk

o Objectives: To review group guidelines; to teach participants what self-talk is and

why it is important to combating anxiety; learn techniques to improve self-talk.


. Part 1: Review group guidelines followed by check-in, “I often wonder ‘What would

happen if______?’”

i. Part 2: Self-talk lesson and discussion.

ii. Part 3: Self-talk techniques (sentence starters, positive affirmations, observing your inner

thoughts)

iii. Part 4: Check-out, “A positive thought I have about myself is ______.”

4. Faulty Thinking

o Objectives: To learn what faulty thinking is and common cognitive distortions;

how it is connected to CBT and ACT; explore how faulty thinking is important to

the experience anxiety.

. Part 1: Check-in, “My highlight of the last week is ______, my lowlight of the last week

is ______.”

i. Part 2: Discussion and lesson on faulty thinking.

ii. Techniques that combat common cognitive distortions.

iii. Part 4: Check-out, “Something I am looking forward to in the next week is ______.”

5. Positive/Effective Communication

o Objectives: To learn ways of communicating with others so that we are clear,

understood, and effective.

. Part 1: Check-in, “A time or place where I feel anxious is ______.”

i. Part 2: Discussion of communication and its importance to daily life.

ii. Part 3: Effective communication techniques (I-messages, do’s and don’ts of assertive

speaking, tips for communicating so that you are heard and understood.).

iii. Part 4: Check-out, “A time or place where I feel my best is ______.”


6. Social Skills Training

o Objectives: To define and demonstrate social skills that help to alleviate social

anxiety.

. Part 1: Check-in, “Something that I wish more people knew about me is ______.”

i. Part 2: To learn what social skills are and brainstorm times and situations where we can

use them.

ii. Part 3: Role play the brainstormed situations with the co-therapists and participants

engaging in this activity. As always, remind the participants that this is voluntary and the co-

therapists can demonstrate, as well.

iii. Part 4: Check-out, “It is easy for me to talk to _______________ because ___________.”

7. Keeping Anxiety at Bay

o Objectives: To begin to plan for the closure of group, introduce “toolkit” of skills

to use in the future; learn what a relapse prevention plan is; learn mindfulness

skills that can be used daily.

. Part 1: Check-in: “I am most myself when I ______.”

i. Part 2: Remind the group that last week is our second last session together, and we will

be developing toolkits next session, we would like to hear any positive experiences that you have

had, participation is voluntary.

ii. Part 3: Learn about a relapse prevention plan, or plan for the future when a challenging

situation may present itself.

iii. Learn about daily techniques that can keep anxiety at bay (mindfulness daily: body scan,

deep breathing, eating mindfully, mindful walking, and relaxing visualization).

iv. Part 4: Check-out, “Describe your dream vacation.”


8. Closing Session

o Objectives: To create “toolkits” for future use when we are in challenging

situations or experiencing anxiety; for those interested complete the RCMAS;

discuss future evaluation and follow-up session.

o Final group evaluations

o Discussion of follow-up sessions

Note Taking and Record Keeping

As discussed in the ethical considerations section above, there are many considerations to

make when working with a group of adolescents. One important ethical consideration is how

notes will be taken and how records will be kept. As clearly stated in the Canadian Code of

Ethics for Psychologists (CPA, 2000), following each meeting with a client a record must be

made of the date, time spent, interventions participated in, and progress towards therapeutic

goals. Our group will record all of this information in individual group files. An example of an

individual client session note is provided in Appendix D. Throughout our sessions we will also

record a general group record where therapists will record what exercises were performed

throughout the group. This record will not have any client information on it, solely information

regarding what the therapists did throughout the session. An example of a group session note is

provided in Appendix E. Both co-therapists are responsible for recording these notes at the end

of each group session. Both co-therapists must initial each individual client session note as well

as group session note indicating consensus on the note that has been recorded. Client and group

files will be locked in a filing cabinet, in a file room with a locked door, meeting CPA (2000)

ethical standards of record storage.


Group Evaluation and Feedback

Though our group is psychoeducational in nature, we do want to evaluate any change that

the participants have experienced as well as hear their feedback about the group itself. In order to

evaluate any individual changes as a result of the group at session eight we will ask the

participants to complete another RCMAS as a post-group measurement. This measurement was

chosen because it is self-report and can be done individually, is brief, and is solely related to the

experience of symptoms of anxiety (Seligman, Ollendick, Langley, & Baldacci, 2004).

Participation in this post-measurement is voluntary and the information will be stored in the

client’s individual file.

Group feedback will be done on a weekly and follow-up basis. Participation in group

feedback is voluntary and anonymous. Each week we will ask the youth to complete a simple

exit slip (see Appendix F) at the end of the group. The slips will be kept in the waiting room on

clipboards outside of the group room so that youth do not feel pressure from the therapists to

complete the evaluation immediately upon being asked. The exit slips will be submitted to the

client services personnel who sits behind a desk at the front of the waiting room, this person will

hand the slips over to the therapists once all participants have left the building. Each week

participants will be reminded of the voluntary and anonymous nature of this feedback. As exit

slips are anonymous they will be stored with the group file. Research indicates that asking group

participants about their experience of a group at the last session can be inaccurate due to feelings

of connection, closure, and warmth to group members (Yalom & Leszcz, 2005). For this reason,

at session eight we will ask the participants to do an exit slip as usual and explain that in two

week’s time we will be phoning them to provide further feedback on the group. Participation in


this final group feedback is voluntary and anonymous and will be stored in the group file

separate from individual client files (see Appendix G for the final group evaluation).


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Appendix A: Parent Marketing Poster

!

!

Is!your!teen!struggling!with!symptoms!of!anxiety?!

T H E ! L E T ! I T ! G O ! G R O U P ! F O R !

A N X I E T Y !

An!8Eweek!program!for!youth!aged!12!to!17!years!old!who!experience!symptoms!of!

anxiety!(negative!selfEtalk,!worrying,!fears,!etc.!that!impact!their!ability!to!enjoy!being!

a!teenager.!!

Participants!will!get!a!chance!to!share!their!experiences!with!each!other,!gain!an!

understanding!of!anxiety,!learn!new!strategies!for!dealing!with!anxiety,!and!reduce!

their!negative!experiences!with!anxiety.!

CALL ! (234) !555 !6789!FOR!MORE! INFORMATION!

ABOUT!THE !PROGRAM!AND!TO!REGISTER !


Appendix B: Youth Marketing Posters


Appendix C: Informed Consent Package









Appendix D: Individual Session Note Template

!

Let It Go Group for Anxiety Individual Client Session Notes

Name: ____________________________ Date:_____________________________ Session #______ of 8

Information and Updates _________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Education Topics Covered and Suggested Activities _________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Comments (include any referrals, specific tasks assigned, always include overall impression of the session) _________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Therapists Initials: _________________________________________________________


Appendix E: Group Session Note Template

!

Let It Go Group for Anxiety Group Session Notes

Date:_____________________________ Session #______ of 8

Education Topics Covered, Suggested Activities, Main Themes Discussed _________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Therapists Initials: _________________________________________________________

Comments (always include overall impression of the session) _________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________


Appendix F: Exit Slip

Weekly Exit Slip for the Let It Go Group for Anxiety

1. What did you like about today’s meeting?

2. What did you dislike about today’s meeting?

3. Would you change anything about today’s meeting? If yes, what?

4. Please provide us with any further comments that you have regarding the group or

today’s meeting:

Thank you for your feedback, it is greatly appreciated.


Appendix G: Final Group Evaluation

Final Participant Evaluation of the Let It Go Group for Anxiety

1. What part of your experience in group did you like the best?

2. What part of the experience in group did you like the least?

3. What is the most important thing that you learning in the group?

4. Have you changed as a result of the group? In what ways?

5. Would you recommend this group to a friend, why or why not?

6. Please share any other comments you have about the Let It Go Group for Anxiety

Thank you for your feedback, it is greatly appreciated.